Download Depression in Older Persons

Depression in Older Persons
How common is depression in later life?
Depression affects more than 6.5 million of the 35 million Americans aged
65 or older. Most people in this stage of life with depression have been
experiencing episodes of the illness during much of their lives. Others may
experience a first onset in late life—even in their 80s and 90s. Depression in
older persons is closely associated with dependency and disability and
causes great distress for the individual and the family.
Why does depression in the older population often go untreated?
Depression in elderly people often goes untreated because many people
think that depression is a normal part of aging—a natural reaction to chronic
illness, loss and social transition. Elderly people do face noteworthy
challenges to their connections through loss, and also face medical
vulnerability and mortality. For the elderly population, depression can come
in different sizes and shapes. Many elderly people and their families don’t
recognize the symptoms of depression, aren’t aware that it is a medical
illness and don’t know how it is treated. Others may mistake the symptoms
of depression as signs of:
• dementia
• Alzheimer’s disease
• arthritis
• cancer
• heart disease
• Parkinson’s disease
• stroke
• thyroid disorders
Also, many older persons think that depression is a character flaw and are
worried about being teased or humiliated. They may blame themselves for
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their illness and are too ashamed to get help. Others worry that treatment
would be too costly. Yet research has also shown that treatment is effective
and, in fact, changes the brain when it works.
What are the consequences of untreated depression in older persons?
Late-life depression increases risk for medical illness and cognitive decline.
Unrecognized and untreated depression has fatal consequences in terms of
both suicide and non-suicide mortality: older Caucasian males have the
highest rate of suicide in the U.S. Depression is the single most significant
risk factor for suicide in the elderly population. Tragically, many of those
people who go on to die by suicide have reached out for help—20 percent
see a doctor the day they die, 40 percent the week they die and 70 percent in
the month they die. Yet depression is frequently missed. Elderly persons are
more likely to seek treatment for other physical ailments than they are to
seek treatment for depression.
Are symptoms of depression different in older persons than in younger
persons?
Symptoms in older persons may differ somewhat from symptoms in other
populations. Depression in older persons is at times characterized by:
• memory problems
• confusion
• social withdrawal
• loss of appetite
• weight loss
• vague complaints of pain
• inability to sleep
• irritability
• delusions (fixed false beliefs)
• hallucinations
Older depressed individuals often have severe feelings of sadness, but these
feelings frequently are not acknowledged or openly shown; sometimes,
when asked if they are depressed, the answer is “no.” Some general clues
that someone may be experiencing depression are:
• persistent and vague complaints
• help-seeking
• moving in a slower manner
• demanding behavior
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How can clinical depression be distinguished from normal sadness and
grief?
It’s natural to feel grief in the face of major life changes that many elderly
people experience, such as leaving a home of many years or losing a loved
one. Sadness and grief are normal, temporary reactions to the inevitable
losses and hardships of life. Unlike normal sadness, however, clinical
depression doesn’t go away by itself and lasts for months. Clinical
depression needs professional treatment to reduce duration and intensity of
symptoms. Any unresolved depression can affect the body. For example,
depression, if left untreated, is a risk for heart disease and can suppress the
immune system, raising the risk of infection.
What causes depression in older persons?
Although there is no single, definitive answer to the question of cause, many
factors—psychological, biological, environmental and genetic—likely
contribute to the development of depression. Scientists think that some
people inherit a biological make-up that makes them more prone to
depression. Imbalances in certain brain chemicals like norepinephrine,
serotonin and dopamine are thought to be involved in major depression.
While some people become depressed for no easily identified reason,
depression tends to run in families, and the vulnerability is often passed from
parents to children. When such a genetic vulnerability exists, other factors
like prolonged stress, loss or a major life change can trigger the depression.
For some older people, particularly those with lifelong histories of
depression, the development of a disabling illness, loss of a spouse or a
friend, retirement, moving out of the family home or some other stressful
event may bring about the onset of a depressive episode. It should also be
noted that depression can be a side effect of some medications commonly
prescribed to older persons, such as medications to treat hypertension.
Finally, depression in the elderly population can be complicated and
compounded by dependence on substances such as alcohol, which acts as a
depressant.
Are some older persons at higher risk for depression?
Older women are at a greater risk: women in general are twice as likely as
men to become seriously depressed. Biological factors, like hormonal
changes, may make older women more vulnerable. The stresses of
maintaining relationships or caring for an ill loved one and children also
typically fall more heavily on women, which could contribute to higher rates
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of depression. Unmarried and widowed individuals as well as those who
lack a supportive social network also have elevated rates of depression.
Conditions such as heart attack, stroke, hip fracture or macular degeneration
and procedures such as bypass surgery are known to be associated with the
development of depression. In general, depression should be assessed as a
possibility if recovery from medical procedure is delayed, treatments are
refused or problems with discharge are encountered.
How is depression in older persons diagnosed?
A physical exam can determine if depressive symptoms are being caused by
another medical illness. Medical concerns and their treatment are common in
this population. A review of the individual’s medications is important: in
some cases a simple medication change can reduce symptom intensity. A
clinical and psychiatric interview is a key aspect of the assessment. Speaking
with family members or close friends may be helpful in making a diagnosis.
Blood tests and imaging studies (like a CT scan) are helpful insofar as they
rule out other medical conditions that would require a different path of
intervention.
Can depression in older persons be treated?
Fortunately, the treatment prognosis for depression is good. Once diagnosed,
80 percent of clinically depressed individuals can be effectively treated by
medication, psychotherapy, electroconvulsive therapy (ECT) or any
combination of the three. A novel treatment—transcranial magnetic
stimulation (TMS)—has been approved by the FDA and may be helpful for
mild depression that has not been helped by one medication trial. Medication
is effective for a majority of people with depression. Four groups of
antidepressant medications have been used to effectively treat depressive
illness: selective serotonin re-uptake inhibitors (SSRIs); norepinephrine and
serotonin reuptake inhibitors (NSRIs); and less commonly, tricyclics and
monoamine oxidase inhibitors (MAOIs). Medication adherence is especially
important, but can present challenges among forgetful individuals. It is
important to note that all medicines have side effects as well as benefits, and
the selection of the best treatment is often made based on tolerability of the
side effects.ECT (also known as shock treatment) may be very useful in the
treatment of severe depression in older adults. For carefully selected people,
ECT can be a lifesaving intervention. For example, an 80-year-old man who
lives alone, has been depressed for months, lost 60 pounds and has delusions
about his body has a kind of presentation that may improve quickly with
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ECT. ECT can impact memory—an important consideration in comparing it
to other interventions.
Medications can be beneficial for elderly individuals in treating the
symptoms of depression. Medications are frequently combined with
supportive psychotherapy or cognitive behavioral therapy to improve their
effectiveness. Research has shown that depressed individuals may need to
try more than one medication to get an optimal response.
Psychosocial treatment plays an essential role in the care of older patients
who have significant life crises, lack social support or lack coping skills to
deal with their life situations. Because large numbers of elderly people live
alone, have inadequate support systems or do not have contact with a
primary care physician, special efforts are needed to locate and identify
these people to provide them with needed care. Natural supports like church
or bridge group colleagues should be encouraged. There are services
available to help older individuals, but the problem of clinical depression
must be detected before treatment can begin.
Like diabetes or arthritis, depression is a chronic disease. Getting well is
only the beginning of the challenge—the goal is staying well. For people
experiencing their first episode of depression later in life, most experts
would recommend treatment for six months to one year after acute treatment
that achieves remission. For persons that have had two or three episodes
during their lifetimes, treatment should extend up to two years after
remission. For peopled with more than three recurrences of depression,
treatment may be life-long. The treatment that gets someone well is the
treatment that will keep that person well.
Reviewed by Ken Duckworth, M.D
October 2009
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